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Case ReportGastrojejunal Anastomosis Perforation after Gastric Bypass ona Patient with Underlying Pancreatic Cancer: A Case Report andReview of the Literature

Omar Bellorin,1 Anna Kundel,2 Alexander Ramirez-Valderrama,1 and Armando Castro1

1Department of General Surgery, New York Hospital Medical Center of Queens/Weill Cornell Medical College, 5645 Main Street,Flushing, NY 11355, USA2Department of Endocrine Surgery, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA

Correspondence should be addressed to Omar Bellorin; [email protected]

Received 28 May 2015; Accepted 20 September 2015

Academic Editor: Muthukumaran Rangarajan

Copyright © 2015 Omar Bellorin et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction.We describe a case of gastrojejunal anastomosis perforation after gastric bypass on a patientwith underlying pancreaticcancer.Case Description. A 54-year-old female with past surgical history of gastric bypass formorbid obesity and recent diagnosis ofunresectable pancreatic cancer presents with abdominal pain, peritonitis, and sepsis. Computerized axial tomography scan showslarge amount of intraperitoneal free air. The gastric remnant is markedly distended and a large pancreatic head mass is seen.Intraoperative findings were consistent with a perforated ulcer located at the gastrojejunal anastomosis and a distended gastricremnant caused by a pancreatic mass invading and obstructing the second portion of the duodenum.The gastrojejunal perforationwas repaired using an omental patch. A gastrostomy for decompression of the remnant was also performed. The patient had asatisfactory postoperative period and was discharged on day 7.Discussion. Perforation of the gastrojejunal anastomosis after Roux-en-Y gastric bypass is an unusual complication. There is no correlation between the perforation and the presence of pancreaticcancer. They represent two different conditions that coexisted. The presence of a gastrojejunal perforation made the surgeon awareof the advanced stage of the pancreatic cancer.

1. Introduction

We present a case of a patient with history of pancreaticcancer and Roux-en-Y gastric bypass for morbid obesity whopresented with acute abdomen secondary to perforation atthe gastrojejunum anastomosis (GJA). The ideology, medicaland surgical treatment, surveillance, and complications ofGJA ulceration are reviewed. The relationship of obesity andcancer and its implications after gastric bypass is alsoaddressed.

2. Case Description

54-year-old female with past surgical history of antecolicantegastric Roux-en-Y gastric bypass in 2004 and recentlydiagnosed with unresectable pancreatic cancer status afterchemotherapy presents with severe left upper quadrantabdominal pain and left sided chest pain which began 12

hours prior. Her current BMI is 35 and she still receives treat-ment for hypertension and diabetes. The pain was sudden inonset, sharp, and radiating to left shoulder. She had no pre-vious episodes and had no recent esophagogastroduodenos-copy (EGD). Physical exam reveals tachycardia, tachypnea,hypotension, and left upper quadrant tenderness and guard-ing consistent with peritonitis. Computerized axial tomogra-phy (CAT) of the abdomen shows moderate to large amountof intraperitoneal free air, likely representing bowel perfo-ration. The gastric remnant is markedly distended and thefree air is only seen in the upper abdomen (Figure 1). Thereis a pancreatic mass obstructing the second portion of theduodenum (Figure 2).

The patient was resuscitated with intravenous fluid andgiven antibiotics and thereafter was brought to the operatingroom for exploratory laparotomy.

Intraoperative findings were consistent with a perforatedulcer located at the GJA and a distended gastric remnant

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2015, Article ID 170901, 4 pageshttp://dx.doi.org/10.1155/2015/170901

2 Case Reports in Surgery

Free air

Figure 1: CT scan of abdomen showing moderate to large amountof intraperitoneal free air, likely representing bowel perforation.

Pancreatic mass

Duodenum's second portion

Figure 2: CT scan of abdomen demonstrating a pancreatic massobstructing the second portion of the duodenum.

caused by a pancreatic mass invading and obstructing thesecond portion of the duodenum. The abdominal cavity wasthoroughly washed and the GJA perforation was repairedusing an omental patch (Graham’s). A gastrostomy fordecom-pression of the remnant was also performed.The patient hada satisfactory postoperative period andwas discharged on day7.

3. Discussion

Patients with gastric bypass may experience a wide varietyof complications that can be classified as acute or chronic.Marginal ulcers of the GJA usually represent a chronic com-plication that the bariatric surgeon encounters frequently.

The reported incidence of marginal ulceration of GJAafter gastric bypass varies widely, ranging from 0 to 16%(Table 1). The risk factors for ulceration are smoking, use ofnonsteroidal anti-inflammatory drugs (NSAIDs) and ster-oids, stress, recent surgery, and the presence of gastrogastricfistulas. Higher incidence has been reported in patientswho underwent gastric bypass using circular staplers for theconstruction of the GJA as opposed to a linear stapler [1–4].

Table 1: Reported incidence of marginal ulceration of GJA aftergastric bypass.

Author Incidence of GJA ulceration (%)Suggs et al. [1] 6.3Higa et al. [12] 1.4Gonzalez et al. [2] 0Lujan et al. [13] 3.4DeMaria et al. [14] 5.1Kligman et al. [3] 0.6Schwartz et al. [4] 0.8MacLean et al. [15] 16

The use of nonabsorbable sutures in theGJA is also associatedwith marginal ulceration [5]. The presence of Helicobacterpylori may additionally play a role in the development ofmarginal ulcers. Schirmer et al. [6] described a 2.4% inci-dence of marginal ulcers in patients who underwent treat-ment forHelicobacter pyloripreoperatively compared to thosewho did not (6.8%).

The majority of these ulcers can be treated medically.However, a subset of patients will have intractable diseaserequiring surgery for definitivemanagement as the last resort.Patients with marginal ulcers are primarily medically treatedwith H2 blockers or proton pump inhibitors. Sucralfate isalso added as well as smoking cessation and substitution ofulcerogenic medications. An upper gastrointestinal study isadvised if a gastrogastric fistula is suspected and/or patientsshow no improvement after medical management. There isno consensus on the length of treatment, but the majority ofbariatric surgeons choose aminimumof two to threemonths’regimen followed by an upper endoscopy for confirmation ofresolution. Some surgeons advocate the endoscopic removalof nonabsorbable sutures, if present [5].

Clinically the symptoms suggestive of marginal ulcera-tion include, but are not limited to, upper abdominal painor progressive upper abdominal discomfort and intoleranceof food and upper gastrointestinal bleed. Intractability isgenerally defined as persistence of symptoms after 3 monthsof medical treatment. Patel et al. [7] reported 39 patientswith intractable marginal ulcers whose primary signs andsymptoms included chronic abdominal pain (66.6%), GIbleeding (20.5%), stomal obstruction (10.2%), and perfora-tion (2.5%). A minority of these patients will present withan acute abdomen similar to the patient we presented, andfree perforation of the ulcer must be ruled out. Perforation ofGJA ulcers is uncommon; the incidence ranges from 0.25 to1% [7–10]. The risk factors for perforation are the same as forulceration; however, smoking, history of recent surgery, andNSAIDs and steroids use are the common denominator inthis particular situation [11].They represent a life-threateningcondition with a mortality rate of 10% [11].

Patients with perforation of a GJA ulcer need aggressivefluid resuscitation and prompt initiation of antibiotic therapyprior to any urgent surgical management. The definitiveapproach can be performed via open surgery or laparoscopyand consists of primary repair of the ulcer and omental patch

Case Reports in Surgery 3

along with a thorough washout of the abdominal cavity. Agastrostomy for feeding purposes should be performed aswell. Large perforations not amenable to primary and patchrepair may require revision of the gastrojejunal anastomosis.

The decision to use laparoscopic approach dependedsolely on the surgeon’s expertise and confidence in advancedlaparoscopy.There are several studies comparing open versuslaparoscopic repair of perforated peptic ulcers that have dem-onstrated better outcomes in the laparoscopic group [16, 17].Shorter hospital stay, reduced wound pain, and earlier returnto normal activities are the main advantages. Kalaiselvan etal. [11] reported a series of 10 patients presented with perfo-rated GJA ulcers. All patients were treated with abdominalwashout, primary closure of the perforation, and omentalpatch. Five patients were operated on by general surgeons viaan open approach and 5 underwent laparoscopic repair bybariatric surgeons.The laparoscopic group experienced lowermorbidity, no mortality, and shorter hospital stay comparedto those who underwent open surgery.

Postoperatively, these patients should have a reduction ofrisk factors, prolonged H2 blockers/proton pump inhibitorsregimen, and eradication of Helicobacter pylori on thosetested positive.

Also an upper endoscopy 3months after the procedure toassess the GJA is recommended.

Obesity and cancer are strongly related. In the UnitedStates, approximately 85,000 new cases of patients with can-cer per year are related to obesity [18]. Studies have found thatan increase of body mass index by 5 kg/m2 is associated witha 10% higher cancer-related mortality. On the other hand,patients who undergo bariatric surgery have a lower inci-dence of cancer and a decrease in cancer-related mortality.This is presumably related to weight loss as demonstratedby Adams et al. [19] in a 12.5-year mean follow-up study ofpatients who underwent gastric bypass surgery compared toseverely obese controls.

Early detection and treatment of cancer in patients under-going bariatric surgery may also play a role. These patientsundergo comprehensive gastrointestinal, pulmonary, andcardiovascular workup preoperatively that is not performedroutinely in the general population. Moreover, the stomachremnant after gastric bypass will no longer be convenientlyaccessible, thus making the preoperative assessment of theupper gastrointestinal tract even more important. Zeni et al.[20] reported the presence of Barrett’s esophagus in preop-erative EGD to be 1.3%, GIST in 0.7%, gastric polyps in 5%,and Helicobacter pylori-associated gastritis and duodenitis in27% and 6%, respectively. This extensive workup may resultin early cancer diagnosis and is possibly part of the reasonwhy patients undergoing obesity surgery have a lower cancer-related mortality.

Once a gastric bypass for obesity is performed, access tothe gastric remnant and the biliary tree becomes complicated.There is no standard recommendation for a routine assess-ment of the gastric remnant after gastric bypass. Althoughtechnically difficult, double balloon enteroscopy is a feasibleway to assess the duodenum and the residual stomachwhen the patient experiences symptoms that warrants further

workup. Ultrasound or CT guided percutaneous gastrostomyand subsequent gastroscopy are another option. Combinedlaparoscopy-endoscopy can be used as last resort for diagno-sis and treatment.

This anatomic exclusion certainly may result in a delayeddiagnosis and treatment of a gastric/duodenal/pancreatic/periampular cancer. A locally advanced pancreatic mass in apatient who has undergone a gastric bypass may result in gas-tric outlet obstruction of the remaining stomach, which maylead to gastric distention, isquemia, and eventual perforationof the gastric remnant. A decompressive gastrostomy of theremnant is the treatment of choice to avoid this complication.

4. Conclusion

Perforation of the GJA after Roux-en-Y gastric bypass is anunusual complication. There is no correlation between theperforation and the presence of pancreatic cancer. They rep-resent two different conditions that coexisted. The presenceof a gastrojejunal perforation made the surgeon aware ofthe advanced stage of the pancreatic cancer that otherwisewould have remained undetected for longer time. Overall theapproach performed on the presented patient correspondsto the standard and the current literature. The laparoscopicapproach by an experienced surgeon may afford the patientthe advantages of minimally invasive surgery.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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4 Case Reports in Surgery

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Case Report Gastrojejunal Anastomosis Perforation after ...downloads.hindawi.com/journals/cris/2015/170901.pdf · Gastrojejunal Anastomosis Perforation after Gastric Bypass on